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Jury Questionnaire

Submitted by Anonymous on Tue, 2013-12-03 10:59

In an effort to select fair and inpartial juries, your cooperation is needed in answering the following questions. The information that you provide will be used by the judge and lawyers during the impaneling of a jury. This questionnaire is provided to attorneys and pro se parties. The information in this questionnaire shall not be otherwised disclosed, nor may it be reproduced.

First Name *

Last Name *

Are you a citizen of the United States? *

Yes

No

Date of Birth (MM/DD/YYYY) *

Marital Status *

Do you have children? *

Yes

No

If you have children, please list their age and gender

If you have adult children, what are their occupations?

What is your county of residence? *

How many years have you lived in this county? *

How many years have you lived in Iowa? *

What is the highest school grade you've completed and/or college degrees? *

What is your occupation or business?

What is the name of your current employer or business? (If retired, list your last employer)

Are you retired? *

Yes

No

Have you ever been in the military? *

Yes

No

If you have been in the military? When?

If you have been in the military, in which branch did you serve?

If you have been in the military, what was the highest rank you earned?

If you are married, what is your spouse's name?

If you are married, what is your spouse's occupation?

How is your health? *

How is your eyesight? *

How is your hearing? *

Have you previously served as a juror? *

Yes

No

If you have previously served as a juror, when?

If you served as a juror, was it in State or Federal Court?

If you served as a juror, what kind of case(s)?

Have you or any immediate family member or near relative ever suffered serious bodily injury? *

Yes

No

Has any immediate family member been killed in an accident of any kind? *

Yes

No

If so, state who was injured or killed, when, the type of injury, and the type of accident

Have you or any immediate family member or near relative ever been a party to a lawsuit other than a divorce? *

Yes

No

If so, who was involved?

What was the nature of the lawsuit?

Was the lawsuit tried or settled?

Yes

No

If the lawsuit was tried, what was the result?

Have you or any immediate family member or near relative ever made a claim for damages for personal injury? *

Yes

No

Has a claim for damages ever been made against you or any immediate family member? *

Yes

No

Are you or any immediate family member or near relative a stockholder, director, officer, employee, or agent of any casualty insurance company? *

Yes

No

If so, who?

What company?

Are you or any of your close friends, immediate family, or relatives a law enforcement officer? *

Yes

No

If so, who?

What law enforcement agency?

Have you or any immedate family member or near relative ever been the victim of a crime? *

Yes

No

If so, when did the crime occur?

Who was the victim of the crime?

What was the nature of the crime?

Have you or any of your close friends, immediate family members, or near relatives ever been arrested or charged with any criminal offense, other than minor traffic offenses? (OWI type offenses should be listed) *

Yes

No

Who and what was your relationship to that person?

What was the nature of the offense?

What websites or blogs do you routinely visit? *

Do you or any of your household possess any firearms? *

Yes

No

If yes, what type of guns?

How are they used?

If Other, please describe:

PLEASE COMPLETE THIS ADDITIONAL INFORMATION

Home Phone (###-###-####) *

Cell Phone (###-###-####)

Email *

Address *

City *

Zip *

Business Name and Address

Business Phone (###-###-####)

Business Supervisor

Are you a Federal Employee?

Yes

No

If so, which agency?

If yes, what are your regular working hours?

If yes, what are your regular days off?

What are the last four digits of your Social Security Number?

Privacy Act Statement: Your social security number is requested on a voluntary basis under authority of section 6041 and 6109 of the Internal Revenue code. If you earn more than $600 in compensation as a juror, the court must inform the Internal Revenue Service using your social security number, and it is helpful to get your number now. Failure to provide your social security number at this time will not disqualify you from serving as a juror, but it may delay jury service payments to which you become entitled.

I hearby certify that the foregoing information is true and correct. Please enter your First and Last name. *